HOUSE BILL No. 5265


     October 17, 2001, Introduced by Reps. Raczkowski, Shulman, George, Howell, Stewart, Julian, Richardville, Woronchak, Basham, Scranton,
Patterson,  Ehardt, Jelinek, Voorhees, Shackleton, Plakas, Kuipers, Pappageorge, Anderson, Vear, Hummel, Gilbert, Vander Veen, Stamas, Allen,
Kooiman, Middaugh, Faunce, Kowall, Cassis, Van Woerkom, Birkholz, DeVuyst, Pumford, Cameron Brown, Sanborn and Neumann and referred to the
Committee on Health Policy.


        A bill to amend 1980 PA 350, entitled

   "The nonprofit health care corporation reform act,"

   by amending section 402a (MCL 550.1402a), as amended by 1998 PA

   426.

               THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

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           Sec. 402a.  (1)  By October 1, 1997, a  A health care corpo-

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      ration shall provide a written form in plain English to subscrib-

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      ers upon enrollment that describes the terms and conditions of

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      the corporation's certificate.  The form shall provide a clear,

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      complete, and accurate description of all of the following, as

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      applicable:

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           (a) The service area.

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           (b) Covered benefits, including prescription drug coverage,

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      with specifications regarding requirements for the use of generic

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      drugs.


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           (c) Emergency health coverages and benefits.

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           (d) Out-of-area coverages and benefits.

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           (e) An explanation of member financial responsibility for

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      copayments, deductibles, and any other out-of-pocket expenses.

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           (f) Provision for continuity of treatment  in the event  IF

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      a provider's participation terminates during the course of a

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      member's treatment by that provider.

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           (g) The telephone number to call to receive information con-

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      cerning member grievance procedures.

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           (h) How the covered benefits apply in the evaluation and

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      treatment of  intractable  pain.   As used in this subdivision

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      and in subsection (2):

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           (i) "Board certified" means certified to practice in a par-

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      ticular medical or other health profession specialty by the

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      American board of medical specialties or other national health

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      professional organization.

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           (ii) "Intractable pain" means that term as defined in sec-

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      tion 16204a(7) of the public health code, 1978 PA 368, MCL

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      333.16204a.

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           (i) A summary listing of the information available pursuant

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      to subsection (2).

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           (2)  By October 1, 1997, a  A health care corporation shall

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      provide upon request to members for services offered pursuant to

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      section 502a a clear, complete, and accurate description of any

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      of the following information that has been requested:

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           (a) The current provider network in the certificate's

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      service area, including names and locations of participating



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      providers by specialty or type of practice, a statement of

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      limitations of accessibility and referrals to specialists, and a

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      disclosure of which providers will not accept new members.

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           (b) The professional credentials of participating health

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      professionals, including, but not limited to, participating

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      health professionals who are board certified in pain medicine and

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      the evaluation and treatment of  intractable  pain and have

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      reported that certification to the health care corporation,

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      including all of the following:

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           (i) Relevant professional degrees.

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           (ii) Date of certification by the applicable nationally rec-

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      ognized boards and other professional bodies.

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           (iii) The names of licensed facilities on the provider panel

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      where the health professional presently has privileges for the

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      treatment, illness, or procedure that is the subject of the

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      request.

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           (c) The licensing verification telephone number for the

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      Michigan department of consumer and industry services that can be

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      accessed for information as to whether any disciplinary actions

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      or open formal complaints have been taken or filed against a

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      health care provider in the immediately preceding 3 years.

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           (d) Any prior authorization requirements and any limita-

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      tions, restrictions, or exclusions, including, but not limited

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      to, drug formulary limitations and restrictions by category of

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      service, benefit, and provider, and, if applicable, by specific

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      service, benefit, or type of drug.





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           (e) Indication of the financial relationships between the

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      health care corporation and any closed provider panel including

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      all of the following as applicable:

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           (i) Whether a fee-for-service arrangement exists, under

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      which the provider is paid a specified amount for each covered

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      service rendered to the participant.

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           (ii) Whether a capitation arrangement exists, under which a

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      fixed amount is paid to the provider for all covered services

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      that are or may be rendered to each covered individual or

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      family.

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           (iii) Whether payments to providers are made based on stan-

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      dards relating to cost, quality, or patient satisfaction.

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           (f) A telephone number and address to obtain from the health

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      care corporation additional information concerning the items

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      described in subdivisions (a) to (e).

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           (3) Upon request, any of the information provided under sub-

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      section (2) shall be provided in writing.  A health care corpora-

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      tion may require that a request under subsection (2) be submitted

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      in writing.

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           (4) AS USED IN THIS SECTION, "BOARD CERTIFIED" MEANS CERTI-

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      FIED TO PRACTICE IN A PARTICULAR MEDICAL OR OTHER HEALTH PROFES-

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      SION SPECIALTY BY THE AMERICAN BOARD OF MEDICAL SPECIALTIES OR

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      OTHER NATIONAL HEALTH PROFESSIONAL ORGANIZATION.











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